Healthcare Provider Details

I. General information

NPI: 1649853078
Provider Name (Legal Business Name): BETHNEY LEAH VAUGHT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

768 S WILLOW AVE STE A
COOKEVILLE TN
38501-3892
US

IV. Provider business mailing address

768 S WILLOW AVE STE A
COOKEVILLE TN
38501-3892
US

V. Phone/Fax

Practice location:
  • Phone: 931-559-6900
  • Fax:
Mailing address:
  • Phone: 931-559-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29187
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number29187
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: